Provider Demographics
NPI:1992960231
Name:BJT MD PLLC
Entity type:Organization
Organization Name:BJT MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:TREACY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-793-9171
Mailing Address - Street 1:PO BOX 6847
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-0847
Mailing Address - Country:US
Mailing Address - Phone:405-793-9171
Mailing Address - Fax:405-793-0815
Practice Address - Street 1:1035 SW 19TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-2883
Practice Address - Country:US
Practice Address - Phone:405-793-9171
Practice Address - Fax:405-793-0815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-25
Last Update Date:2012-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23781207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200263670AMedicaid
OKOKB5637Medicare PIN